Madera Rehabilitation & Nursing Center

In the surveyor’s words

From the most serious findings on record at Madera Rehabilitation & Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Mar 7, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance to prevent falls for three of six sampled residents (Residents 1, 2 and 6) when: 1. Resident 1 was assessed as being a fall risk, had poor safety awareness and needed to be supervised while ambulating (walking) and the facility did not implement effective interventions to prevent falls, including adequate supervision, consistent with the resident ' s needs, goals and care. […]

• Actual harm, isolatedF689Aug 14, 2025

  Based on observations, interviews and record review, the facility failed to ensure residents' environment remained free of accident hazards as possible when: 1. In the memory care unit, facility staff were aware an exit door was secured by a slide barrel lock (a type of lock that requires the user to slide the barrel of the lock in order to unlock the device) and placed on the door in a position that was out of reach for most individuals. An environmental hazard risk assessment was not done for the lock on the door. […]

• Actual harm, isolatedF692Aug 14, 2025

  Based on interview, and record review, the facility failed to ensure two of sixteen sampled residents (Resident 2 and Resident 4) maintained acceptable parameters of nutritional status when:1. Resident 2 was at risk of unplanned weight loss, and did not receive adequate nutritional interventions to maintain acceptable parameters of nutritional status. This failure resulted in a severe weight loss of 7.95% in less than 2 months from 6/2/25 to 7/28/25 without timely assessment, monitoring, or physician notification. 2. […]

• Actual harm, isolatedF689Apr 15, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent falls for two of five sampled residents (Residents 1 and 9) when: 1. Resident 1 was assessed to be at risk for falls on 3/23/25 and staff were aware of Resident 1's frequent positioning in bed lying on his back leaning against the side rail, right sided paralysis (inability to move), and inability to reposition himself and effective individualized interventions to prevent falls were not implemented. […]

• Actual harm, isolatedF689Jan 9, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance to prevent falls for two of five sampled residents (Residents 2 and 8) and to prevent elopement for one of two sampled residents (Resident 1) when: 1. Nursing staff were aware of Resident 2 ' s decline in functional status, poor safety awareness and need to be supervised while ambulating and failed to assign staff to supervise Resident 2. On 1/2/25 Resident 2 was left unsupervised, and he ambulated unassisted to the outdoor patio where he was found on the ground after an unwitnessed fall. […]